Case history -6


This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

October18,2021

Date of admission:15/10/21

 

A 50 yr old male presented to the opd with the chief complaint of pedal edema since 3 months on and off along with facial puffiness .

Decreased urine output since 3 months and SOB of grade 4 since 3 days .


HISTORY OF PRESENT ILLNESS:patient was apparently asymptomatic since 3 months back then developed bilateral pedal edema which is Pitting type and progression in nature and extending until knee .c/o sob grade 4 .no h/o abdominal distensions ,loose stools ,vomitings ,fever,coughetc..


HISTORY OF PAST ILLNESS :

Not a k/c/o HTN/DM/TB/CAD/ASTHMA/CVA .


PERSONAL HISTORY:

Married ,normal appetite,non vegetarian,regular bowel movement,micturation -normal ,no known allergies ,no addictions .


FAMILY HISTORY:

No history of diabetes, hypertension, heart disease, stroke, asthma, tuberculosis,cancers .


General examination:

The patient is conscious, coherent, cooperative.

Palar-present 

No cyanosis 

No lymphadenopathy 

No malnutrition 

No dehydration 

No clubbing 

No icterus 

Edema -present


VITALS :
Temp :afebrile 
Pulse rate:100/min 
Respiratory rate:26cpm 
Bp:160/90 mm/hg 
Spo2-97%at 8L of o2
Grbs -180mg %

SYSTEMIC EXAMINATION:

CVS  :
No thrills 
No cardiac murmurs 
Cardiac sounds-s1,s2 heard 

RESPIRATORY SYSTEM :
Dysponea-present 
No wheeze 
Position of trachea-central 
Breath sounds-vesicular 

ABDOMEN:
Shape of abdomen-scaphoid 
No tenderness 
No palpable mass 
Hernial orifices-normal 
No free fluid 
No bruits 
Liver ,spleen-not palpable 
Bowel sounds -yes 

CNS:
Conscious 
Normal speech 
No neck stiffness 
No kernings signs 
Cranial nerves ,motor and sensory system,glasgow scale -normal .

REFLEXES :
Plantars -flexor 

CEREBRAL SIGNS:
No finger -nose in -coordination 
No knee -heel in -coordination.

PROVISIONAL DIAGNOSIS:
Chronic kidney disease 

INVESTIGATIONS:
15/10/21













16/10/21






TREATMENT:

-Tab .LASIX 40 mg Po/BD 

-Tab NODOSIS 500mg PO OD 

-Tab .PAN 40 mg OD 

-Tab SHELLAC CT PO OD 

-Tab OROFER XT PO BD 

-inj iron sucrose 1amp in 100 ml IV  Weekly once 

-inj erythropoietin 4000 IU/SC weekly once 

-O2 inhalation if spo2<90 % 

-strict I/O Charting 

-BP/PR/RR monitoring 4th hrly.



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